Optimizing delirium assessment, management, and prevention

DIMS-PLUS5 framework

The mnemonic acronym DIMS—derived from drug, infection, metabolic, and structural and systems—is commonly used to aid in the assessment of delirium triggers. Although it is a concise tool, the DIMS framework only covers the most overt triggers. Delirium is often multifactorial, involving a complex interplay of predisposing and precipitating factors.^2,3 Therefore, to prevent, identify, and treat all provoking elements, we propose to expand DIMS to include pain, liquids and solids, urine and bowels, and 5 s’s—senses, sleep, setting, stasis, and stress—resulting in the DIMS-PLUS5 framework (Table 1).

The assessment of a patient with delirium begins by conducting a thorough history (including collateral history and chart review) and physical examination. It is extremely important to review drug history and account for recent changes, adherence, and the use or misuse of alcohol, substances, or over-the-counter products. The addition of PLUS5 to DIMS ensures that a comprehensive evaluation is performed, with attention paid to both patient and environmental factors. Moreover, frail individuals might develop delirium as a result of seemingly innocuous changes that are often multifactorial; consideration of PLUS5 factors can help to identify these subtle, provoking changes. Using a structured approach to assessment is beneficial because diseases might manifest atypically in older individuals, particularly in those who are frail, without presentation of the usual signs, symptoms, and findings.^3,4

This framework also helps direct the relevant workup, guided by clinical assessment and patient goals of care. Box 1 outlines the tests indicated for most patients with delirium according to national guidelines.³

Depending on the clinical scenario, additional tests might be indicated (ie, neuroimaging, drug blood level, toxicology, troponin, electroencephalogram, lumbar puncture, or other relevant tests). The U in PLUS5 (urine and bowels) reminds the clinician to consider including a postvoid residual urine test and abdominal x-ray scan among the initial investigations to assess for urinary retention and constipation. Testing for micronutrient deficiencies, particularly vitamin B12 deficiencies, is also prudent, as highlighted by “liquids and solids.” Wernicke encephalopathy (caused by thiamine deficiency) should be considered in any patient with delirium and malnutrition, as it often presents without all of the classic features, but is easily treated.⁵

Clinicians are adept at recognizing and managing DIMS triggers; however, the PLUS5 acronym can help guide treatment and prevention of delirium by ensuring all provoking factors are addressed. Interventions recommended by the Canadian Coalition for Seniors’ Mental Health national guidelines on delirium (first published in 2006 and updated in 2014) are summarized in this framework.^3,6 These include optimizing the following: pain control, ideally through the safest available scheduled regimens (pain); oral hydration and nutrition by ensuring adequate nutrient intake, with additional consideration for daily multivitamins or thiamine replacement or both (liquids and solids); bowel and urine habits, with preference for intermittent catheterization to treat urinary retention (urine and bowels); vision, hearing, and communication, addressing deficits through the use of glasses, amplification devices, and interpreters when appropriate (senses); sleep habits, focusing on nonpharmacologic measures and decreasing nocturnal disturbances (sleep); reorientation strategies by avoiding unnecessary environment transitions, having a quiet room with windows, and involving family presence and familiar possessions (setting); physical activity and avoiding restraints (stasis); and de-escalation protocols and behavioural management strategies (stress).^3,6 Programs based on these optimizing principles, such as the Hospital Elder Life Program, have been shown to be effective at preventing delirium.^2,3